Intraoperative Indocyanine Green Angiography for Fat Necrosis Reduction in the Deep Inferior Epigastric Perforator (DIEP) Flap

Abstract

Background Fat necrosis is a frequent complication (up to 62.5%) of microsurgical breast reconstruction using the deep inferior epigastric perforator (DIEP) flap. This could have important clinical and psychological repercussions, deteriorating the results and increasing reconstruction costs. Objectives The aim of this study was to demonstrate the intraoperative use of indocyanine green angiography (ICGA) to reduce fat necrosis in DIEP flap. Methods Sixty-one patients who underwent unilateral DIEP flap procedures for breast reconstruction after oncological mastectomy were included (24 cases with intraoperative use of ICGA during surgery, 37 cases in the control group). The follow-up period was 1 year after surgery. The association between the use of ICGA and the incidence of fat necrosis in the first postoperative year, differences in fat necrosis grade (I-V), differences in fat necrosis requiring reoperation, quality of life, and patient satisfaction were analyzed. Results The incidence of fat necrosis was reduced from 59.5% (control group) to 29% (ICG-group) (P = 0.021) (relative risk = 0.49 [95% CI, 0.25-0.97]). The major difference was in grade II (27% vs 2.7%, P = 0.038). The number of second surgeries for fat necrosis treatment was also reduced (45.9% vs 20.8%, P = 0.046). The ICG group had higher scores on the BREAST-Q. Conclusions Intraoperative ICGA is a useful technique for reconstructive microsurgery that might improve patient satisfaction and reduce the incidence of fat necrosis by half as well as reduce its grade, especially in small fat necrosis cases; consequently, ICGA could reduce the number of secondary surgeries for treatment of fat necrosis. Level of Evidence: 4

Abdominal subcutaneous fat thickness as a substitute for BMI in predicting complications in abdominally‐based autologous breast reconstruction

“…While patients with a thicker abdominal fat pad may be at increased risk for flap fat necrosis, intraoperative precautions may improve outcomes. Among these are increasing the number of perforators the flap is based on as well as using intraoperative tools such as indocyanine green angiography to assess flap perfusion, which have previously been shown to reduce fat necrosis occurrence rates (Hembd et al, 2020; Malagón‐López et al, 2019; Momeni & Sheckter, 2020).…”

Fat-Augmented Latissimus Dorsi versus Deep Inferior Epigastric Perforator Flap: Comparative Study in Delayed Autologous Breast Reconstruction

“…These findings are in agreement with other studies reporting on breast reconstruction complications, with the DIEP flap to be associated with higher early flap-related complication rates, compared with other autologous or implant-based reconstructive methods. 30,31 Use of new modalities, such as preoperative infrared thermography 32 or intraoperative fluorescent angiography with indocyanine green 33,34 has recently been suggested as a useful tool for reducing perfusion-related problems, that is, flap ischemia and fat necrosis.…”

Increase of major complications with a longer ischemia time in breast reconstruction with a free deep inferior epigastric perforator (DIEP) flap

“…More often, an ICG-camera is used to assess the blood flow in a flap. The ICG-camera can also be used in free flap operations but does not distinguish the cause of the reduced blood flow [17,18]. It would be interesting to develop a method to investigate and distinguish the various causes of tissue damage.…”